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Summary Background Evidence-based treatment for hypercholesterolaemia in Japan has been hindered by the lack of direct evidence in this population. Our aim was to assess whether evidence for treatment with statins derived from western populations can be extrapolated to the Japanese population. Methods In this prospective, randomised, open-labelled, blinded study, patients with hypercholesterolaemia (total cholesterol 5·69-6·98 mmol/L) and no history of coronary heart disease or stroke were randomly assigned diet or diet plus 10-20 mg pravastatin daily. The primary endpoint was the first occurrence of coronary heart disease. Statistical analyses were done by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00211705. Findings 3966 patients were randomly assigned to the diet group and 3866 to the diet plus pravastatin group. Mean follow-up was 5·3 years. At the end of study, 471 and 522 patients had withdrawn, died, or been lost to follow-up in the diet and diet plus pravastatin groups, respectively. Mean total cholesterol was reduced by 2·1% (from 6·27 mmol/L to 6·13 mmol/L) and 11·5% (from 6·27 mmol/L to 5·55 mmol/L) and mean LDL cholesterol by 3·2% (from 4·05 mmol/L to 3·90 mmol/L) and 18·0% (from 4·05 mmol/L to 3·31 mmol/L) in the diet and the diet plus pravastatin groups, respectively. Coronary heart disease was significantly lower in the diet plus pravastatin group than in the diet alone group (66 events vs 101 events; HR 0·67, 95% CI 0·49-0·91; p=0·01). There was no difference in the incidence of malignant neoplasms or other serious adverse events between the two groups. Interpretation Treatment with a low dose of pravastatin reduces the risk of coronary heart disease in Japan by much the same amount as higher doses have shown in Europe and the USA. [ABSTRACT FROM AUTHOR]